Marital Satisfaction and Depression in Mothers of 3-4 Year Old Children with Developmental Delay in Comparison with Mothers of Normal Children.

Objectives The present study evaluated the depression and marital satisfaction in mothers of 36-48 months old children with developmental delay in comparison with mothers of normal children. Materials & Methods This cross-sectional study was performed on 616 mothers and their children, aged 36 - 48 months, from Apr 2015 to Feb 2016, in some kindergartens in Tehran, Iran. Participants were selected through multi-stage random sampling. The children were divided according to the developmental status into two groups of normal development and developmental delay. The following instruments were used: A demographic and children specification questionnaire, marital satisfaction scale, the Beck Depression Inventory, and the Ages and Stages Questionnaire. The data were analyzed using SPSS16 software. Independent t-test and Pearson correlation were employed at significance level of 0.05. Results The mean age of children with developmental delay and normal development was 41.94±4.48 and 42.17±5.02 months, respectively. The prevalence of developmental delay in children aged 36-48 months was 17.4% and in normal development children was 82.6%. Developmental delay in boys was 23%. The highest incidence of developmental delays was in fine motor skills. Independent t-test revealed a significant difference between mothers' depression and marital satisfaction with and without developmental delays in their children (P=0.0001). In addition, the correlation was observed between the mother’s depression and marital satisfaction (P=0.0001). Conclusion Mothers of children with developmental delay suffer more from depression and have less marital satisfaction compared to mothers of healthy children. Interventional studies to reduce depression and increase marital satisfaction and its impact on development status should be conducted.


Introduction
Developmental disorders are one of the most common problems in children (1). From birth through age of 5 yr is the critical time in developing cognitive, social, emotional, lingual, physical and behavioral skills and it forms the basis of new skills as well as experiences in adulthood (2).
Examining the evolution of the development is done in five domains: communication, gross motor, fine motor, problem-solving, and personalsocial skills (3).
A child might suffer from developmental delay in one or several domains, which may decrease their total developmental score (4). Once children fail to gain their developmental capabilities, they are diagnosed with developmental disorder (5).
The risk of developmental delay depends on the relationship between biological and psychological factors (6), thus it is difficult to diagnose its etiology (7). This issue has huge impacts on their health and society at wider scale (8).
The prevalence of developmental disorders in North America and Australia is estimated between 12% and 17% and in Iran from 7%-22% (9-17), with 18% incidence among children aged 4-60 months in Tehran and in other places as 14.6% (18,19). About 8% of preschool-aged children, The presence of a disabled child can also cause irreparable damage to mental health of the family.
Iran J Child Neurol. Autumn 2019 Vol. 13 No. 4 Parents might severely suffer from having an affected child and might experience depression, anxiety, aggression, fear and shame, or they might even wish to die (33). Parents of such children have less mental health, higher levels of anxiety, depression, and physical problems, and social performance disorder in comparison with parents of normal children (34,35).
In view of the important role of mothers in caring, communicating with, and educating the child (36-38) and the traditional role of mothers as "caregiver", she carries more responsibility with regard to taking care of the retarded child.
Consequently, she would be exposed to more mental problems and higher risk of mental-health related problems (30, 39).

The level of general health and psychological
wellbeing of mothers of children with mental retardation is also reported lower and the anxiety higher compared to mothers with normal children (40,41 (68) in parents, self-blame, having problem in adapting to and coping with child's problems (69).
The rate of divorce is the most reliable indicator of marital disturbance (70) and it shows the difficulty in having marital satisfaction (71). In fact, divorce has a direct correlation with marital satisfaction although the rate of divorce is not a true indicator of marital satisfaction (72). Overall, 80% of divorce were reported in families with retarded children while the national statistics were indicative of less than 50% of divorce rate (73). Health of mothers, and women in general is considered the pillar of a healthy society. Mother's health, a key underlying factor for health of the family and society, is also the fundamental concept in socioeconomic development and wellbeing.
Considering the importance of mothers' role in taking care, nurturing and building relationships with the child and the consequences of having developmental delay, we evaluated depression and marital satisfaction in mothers of children with and without developmental delay.

Study Design and Population
This cross-sectional descriptive study was

Inclusion and exclusion criteria
The eligible subjects were: • Mothers who had not experienced any serious stressful and unpleasant events (such as loss) for six months before the study.
• Mothers with history of children with developmental disorder" were excluded from the study.
Incomplete questionnaires were completed due to excluded from the study.

Materials & Methods
The present cross-sectional study recruited 616 mothers and their 36-48 months old children.
The children were divided according to the developmental status into two groups as normal development and developmental delay.
The first stage of sampling employed stratified sampling technique and then every stratum was randomly selected considering the number of kindergartens in every municipal district such that 8, 17, and 10 kindergartens were selected from north, center, and south part of the city. The samples were selected purposefully from each kindergarten considering the inclusion criteria.

Measuring tools
The data collection instruments included parentschild demographic inventory, socioeconomic questionnaire. The demographic and obstetric inventory included parents' general information The items have the following five options with scores ranging from 1 to 5 respectively: "Strongly disagree", "Disagree", "Neither agree nor disagree", "Agree", "Strongly agree". This scale has four distinct scores while a total score was given to sum of the items of each scale.
The raw scores were converted into percentage. For screening of depression, The Beck Depression Inventory-II (BDI-II) was used, also 21 items scoring from 0 to 63 most commonly utilized for measurement of depression.
In Iranian population, the internal consistency was confirmed with Cronbach's alpha of 0.87 and reliability coefficient was found at 0.74 (87). The reliability of the questionnaire was measured as 0.85, using Cronbach's alpha.

ASQ Questionnaire
ASQ is currently the most widely used to determine the developmental status. Sensitivity of the ASQ test is 75% in high risk group and 100% in the community group, with specificity of 95% and 90%, respectively (88).
Validity of this test varies from 76% to 88% and The reliability of this scale in present study was obtained as 0.83, using the test-retest method.

Ethical Considerations
Written consent forms were obtained from mothers and they were asked to fill out the following questionnaires at home in four days. This study was

Data Analyses
After obtaining the required permission for conducting the research, objectives were explained to authorities and instructors. The consent and cooperation of kindergarten instructors were also obtained. Demographic questionnaire of mother and child, Beck's Depression Inventory, Enrich Marital Satisfaction Scale, and Ages and Stages Questionnaire (ASQ) according to age of the child The scores of ASQ were calculated with regard to cutoff points set for the age of the child. The results were reported to mothers and they were referred to special centers if the scores were lower than cut-off points. Mothers with high depression scores, according to BDI, were referred to as consultancy services.
The data were analyzed using SPSS version 16 (Chicago, IL, USA) by t-test, Chi-square and Pearson's correlation at significance level of 0.05.

Results
The mean age of mothers of children with developmental delay was 30.385.42± yr while it was 31.635.50± yr in mothers with normal children. The mean age of fathers of children with developmental delay and normal children was 34.375.141± and 36.125.974± yr, respectively. Most mothers with developmental delay children had 12.254.22± yr of education while it was 11.884.714± yr for mothers of normal children. No significant difference was observed between the group of children with delayed development and normal development of their parents mean age and education (by in depended t-test).
The majority of mothers in both groups were housewives (63.3%) and fathers were employees (44.3%). Of the 616 children 36-48 months, 51.9% being female and 48.1% being male. Overall, 107 children (17.4%) were in developmental delay group and 82.6% were in normal developmental group. The median number of pregnancy was two and the number of childbirth was one in both groups so there was no significant difference between the two in these regards. The prevalence of developmental delay was 17.4% with 12.2% and 23% in females and males, respectively. The highest prevalence of developmental delay was in fine motor (6.5%) and the lowest in personal social domains (4.2%) ( Table 1)  The results of the present study were indicative of significant differences between child gender and his/her development (P=0.0001), by Chisquare test and socioeconomic status (P=0.044) by Mann-Whitney test. The independent t-test showed significant differences between mother's depression and marital satisfaction in mothers of children with and without developmental delay ( Table 2). The correlation between depression and marital satisfaction was also significant (P=0.0001).  Depression is a psychological problem that causes mood disorder and decreases libido. A correlation between outbreaks of depression symptoms and poor marital relationship is reported (102).
The results of the present study showed that marital satisfaction in mothers of children with developmental delay was lower than that in mothers of normal children, aligned with other studies (64, 103,104). Parents of mentally retarded children reported poor marital satisfaction (105).
The odds of divorce in parents of disabled children were higher than the national statistics (73).
On the contrary, a disabled child did not consider as a reason for marital distress (106)  Afraz F: data collection.
All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Conflict of interest
The authors declare that there is no conflict of interests.